Evolving trends in the initial locoregional management of male breast cancer

Accuracy of sentinel lymph node biopsy in male breast cancer: Systematic review and meta-analysis

BACKGROUND

Sentinel lymph node biopsy (SLNB) is commonly used in the surgical management of male breast cancer. Contrary to female breast cancer, limited data exist about its performance in male breast cancer. The objective of this systematic review and meta-analysis was to evaluate the SLNB accuracy in male breast cancer.

METHODS

MEDLINE, EMBASE, Web of Science and The Cochrane Library were searched from January 1995 to April 2023 for studies evaluating the SLNB identification rate and false-negative rate in male breast cancer with negative preoperative axillary evaluation and primary surgery. For SLNB false-negative rate, the gold standard was the histology of axillary lymph node dissection (ALDN). Methodological quality was assessed by using the QUADAS-2 tool. Pooled estimates of the SLNB identification rate and false-negative rate were calculated. Heterogeneity of the pooled studies was evaluated using I2 index.

RESULTS

A total of 12 retrospective studies were included. The 12 studies that reported the SLNB identification rate gathered a total of 164 patients; the 5 studies that reported the SLNB false-negative rate gathered a total of 50 patients with a systematic ALND. The pooled estimate of the SLNB identification rate was 99.0%. The SLNB false-negative rates were 0% in the 5 included studies and consequently so as the pooled estimate of the false-negative rate with no heterogeneity.

CONCLUSION

SLNB for male breast cancer, following negative preoperative axillary assessment and primary surgery, appears feasible, consistent, and effective. Our research supports conducting immediate SLNB histological evaluation to facilitate prompt ALND in case of positive results.

Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ in Males: An NCDB Analysis of the Surgical Approach to DCIS in Males

BACKGROUND

Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS.

METHODS

The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier.

RESULTS

Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08).

CONCLUSIONS

The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.

Oncotype DX for Comprehensive Treatment in Male Breast Cancer: A Case Report and Literature Review

Male breast cancer (MBC) is uncommon in clinical practice. Using the 21-gene assay to facilitate decision-making on comprehensive treatment of MBC is rarely reported. This study reports the case of a 53-year-old man with left breast cancer. Modified radical mastectomy was performed. Endocrine treatment was chosen for the patient according to the result of the 21-gene assay, a recommended genomic test of breast cancer. The patient remained in good health without evidence of recurrence at 18-month follow-up. This case provides a reference mode for the comprehensive management of early-stage, estrogen receptor–expressing and lymph node–negative MBC patients.

Epidemiology and practice patterns for male breast cancer compared with female breast cancer in Japan

BACKGROUND

The incidence of male breast cancer (MBC), although rare, has shown an increase. However, the current epidemiology of and practice patterns for MBC remain unclear. This study evaluated the characteristics and care patterns for MBC compared with female breast cancer (FBC) in Japan.

METHODS

Using the National Database of Hospital-Based Cancer Registries (HBCR) linked to the Diagnosis Procedure Combination data, we analyzed newly diagnosed breast cancer cases between January 2012 and December 2015 at participating hospitals in a large quality-of-care monitoring project. We employed logistic regression models to assess cancer treatment differences between MBC and FBC in patients who were indicated for adjuvant radiation therapy and neo-adjuvant/adjuvant chemotherapy.

RESULTS

Of 142,636 breast cancer patients, 870 (0.61%) were MBC patients. At diagnosis, the mean age of MBC patients was 10 years older than FBC patients (70 vs 60 years; P < .001). Advanced-stage cancer was more frequently observed in MBC than in FBC (stage III/IV 18.9%/6.1% vs 10.6%/5.2%). Despite this, MBC patients were less likely to receive adjuvant radiation therapy and neo-adjuvant/adjuvant chemotherapy. Gender was an independent treatment determinant factor for chemotherapy decisions.

CONCLUSION

MBC patients were older and had higher stages of cancer than FBC patients at diagnosis, but received suboptimal treatment.

Image-based screening for men at high risk for breast cancer: Benefits and drawbacks

Male breast cancer is a rare malignancy. Due to low prevalence and limited data to support male breast cancer screening, there are currently no recommendations for image-based screening in asymptomatic men and few recommendations for men at high risk for breast cancer. However, symptomatically diagnosed cancers in men are typically advanced, suggesting that earlier detection may improve outcomes. In this article we briefly review the risk factors for male breast cancer, and discuss the potential benefits and possible drawbacks of routine image-based screening for men at high risk for breast cancer.

Saving the Male Breast: A Systematic Literature Review of Breast-Conservation Surgery for Male Breast Cancer

BACKGROUND

Male breast cancer (MBC) management is extrapolated from female BC. Mastectomy remains the most frequently used surgical procedure for male breast cancer (MBC). We performed a literature review to assess the use of breast-conservation (BCS) in MBC as well as outcomes following BCS.

METHODS

A systematic literature was performed, and articles screened to identify studies that measured overall survival (OS), disease-free survival (DFS), or local recurrence (LR) in patients undergoing BCS. Weighted averages based on study size were performed for LR, DFS, and 5-year OS.

RESULTS

Eight studies met the inclusion criteria with male breast surgery cases, and 859 (14.7%) underwent BCS. The mean follow-up time was 53 months, and mean age was 62.6 years, with stage II as the most common presentation. Two studies reported that 50-71.4% of patients underwent sentinel lymph node biopsy, and four studies reported axillary lymph node dissection in 14.3-100%. Five studies reported on adjuvant radiation therapy in 12.0-100% of total patients undergoing BCS. Four studies reported use of hormonal therapy in 73.8-100% of patients. Four studies reported use of chemotherapy in 25-66.7% of patients. Seven studies reported LR among 116 patients, with a weighted average of 9.9%. Three studies reported on DFS in 14 patients, with a weighted average 85.6%. Two studies report OS in 143 patients with a weighted average of 84.4%.

CONCLUSIONS

Breast conservation may be considered a safe alternative in the surgical treatment of MBC. Future research should focus on better standardization of local therapy for MBC and improved reporting of outcomes.

A contemporary review of male breast cancer: current evidence and unanswered questions

Male breast cancer is rare, accounting for 1% of all breast cancer diagnoses in the USA. Because of its rarity, most major breast cancer trials have included only female patients. This has resulted in limited prospective data to guide the clinical management of men with breast cancer. As a result, treatment decisions are typically extrapolated from data generated in female patients. This approach may be suboptimal, particularly considering the differing hormonal milieus between men and women with respect to both breast cancer development and treatment. Herein, we summarize current knowledge of the biology and clinicopathology of male breast cancer and review current approaches to locoregional and systemic management of this rare disease.

Radiotherapy and Male Breast Cancer: A Population-based Registry Analysis

BACKGROUND

The local-regional management of female breast cancer has been extensively investigated worldwide. The optimal approach for males diagnosed with breast cancer is less clear. We have analyzed the treatment of male breast cancer using a population-based national registry to determine the impact of surgery and radiation therapy on survival.

MATERIALS AND METHODS

The Surveillance Epidemiology and End Results (SEER) database was queried to identify males with invasive ductal carcinoma of the breast who underwent primary surgical resection (radical mastectomy, modified radical mastectomy, total mastectomy, or segmental) for the years 1983 to 2002. Demographic, clinical, and pathologic data were culled and analyzed to determine the impact of radiation therapy (RT) following resection. Survival rates were estimated using the Kaplan-Meier method and significance was determined using the log-rank test (P<0.05). Multivariate analysis with the Cox proportional hazards model was performed to determine factors significant for overall (OS) and cause-specific survival (CSS).

RESULTS

A total of 1337 patients met the eligibility criteria and were analyzed. Median follow-up was 7.3 years (range, 1 mo to 25 y). Most men underwent modified radical mastectomy (n=1062) with a minority undergoing segmental (n=113). About 329 men received postoperative external beam RT. The median rates of OS and CSS for all men were 10.5 years and not yet reached, respectively. The surgical procedure did not significantly associate with OS or CSS. By stage, RT was associated with improved OS for stage I (P=0.03). There was a trend for improved survival with stage II (P=0.21) and III (P=0.15). RT was not associated with improved CSS by stage. RT improved rates of OS and CSS in N2 patients without reaching statistical significance (P=0.10 and 0.22). On multivariate analysis, advancing age, stage and grade, and no postoperative RT predicted for worse OS. However, when controlled for those with known hormone receptor status (n=978), only the factors of advancing age, stage, grade, and hormone receptor negativity predicted for worse OS. Advancing age, stage, and grade were the only predictors of CSS irrespective of the cohort analyzed.

CONCLUSIONS

The primary surgical procedure did not ultimately influence OS or CSS in this population-based registry of males with breast cancer. A statistically nonsignificant improvement with postoperative RT was observed in men with lymph node involvement, larger tumor size, or higher stage. When controlled for age, stage, and grade in multivariate analysis, postoperative RT predicted for improved OS but not CSS. These data suggest a beneficial effect of RT in the postoperative setting. A prospective study is necessary to further elucidate appropriate treatment strategies for men with breast cancer.

Long-term survival and BRCA status in male breast cancer: a retrospective single-center analysis

Background

Male breast cancer (MBC) is rare. Given the paucity of randomized trials, treatment is generally extrapolated from female breast cancer guidelines.

Methods

This is a retrospective analysis of all male patients presenting with MBC at the Department of Oncology at University Federico II of Naples between January 1989 and January 2014. We recorded the following data: baseline characteristics (age, height, weight, body mass index, risk factors, family history), tumor characteristics (side affected, stage, histotype, hormonal and HER2 status, and Ki-67 expression), treatment (type of surgery, chemotherapy, endocrine therapy, and/or radiotherapy), BRCA1/2 mutation status (if available), other tumors, and long-term survival.

Results

Forty-seven patients were analyzed. Median age was 62.0 [55.0–72.0]. Among risk factors, obesity and family history of breast cancer were associated with 21 % and 30 % of MBC cases, respectively. The majority of tumors were diagnosed at an early stage: stage I (34.0 %) and stage II (44.7 %). Infiltrating ductal carcinoma was the most frequent histologic subtype (95.8 %). Hormone receptors were generally positive (88.4 % of cases were Estrogen receptor [ER] positive and 81.4 % Progesteron receptor [PgR] positive). Human epidermal growth factor receptor 2 (HER2) was positive in 26.8 % of cases; 7.0 % of MBCs were triple negative. The tumor had high proliferation index (Ki67 ≥ 20 %) in 64.7 %. Surgery was predominantly mastectomy (85.1 %), whereas quadrantectomy was performed in 14.9 % of patients. Adjuvant chemotherapy was administered to 70.7 % of patients, endocrine therapy to 90.2 %, trastuzumab to 16.7 % and radiotherapy to 32.6 %. BRCA status was available for 17 patients: 10 wild-type, 1 BRCA1 carrier, 5 BRCA2 carriers, 1 unknown variant sequence. The overall estimated long-term survival was about 90 % at 5 years, 80 % at 10 years and 70 % at 20 years. Patients carrying a BRCA mutation had a significantly lower survival than patients with wild-type BRCA (p = 0.04).

Conclusions

Long-term survival was high in MBC patients referred to our clinical unit. Survival was poorer in BRCA-mutated patients than in patients with wild-type BRCA.

Expression of phosphorylated eIF4E-binding protein 1, but not of eIF4E itself, predicts survival in male breast cancer

Background:

Male breast cancer is rare and treatment is based on data from females. High expression/activity of eukaryotic initiation factor 4E (eIF4E) denotes a poor prognosis in female breast cancer, and the eIF4E pathway has been targeted therapeutically. Eukaryotic initiation factor 4E activity in female breast cancer is deregulated by eIF4E overexpression and by phosphorylation of its binding protein, 4E-BP1, which relieves inhibitory association between eIF4E and 4E-BP1. The relevance of the eIF4E pathway in male breast cancer is unknown.

Methods:

We have assessed expression levels of eIF4E, 4E-BP1, 4E-BP2 and phosphorylated 4E-BP1 (p4E-BP1) using immunohistochemistry in a large cohort of male breast cancers (n=337) and have examined correlations with prognostic factors and survival.

Results:

Neither eIF4E expression nor estimated eIF4E activity were associated with prognosis. However, a highly significant correlation was found between p4E-BP1 expression and disease-free survival (DFS), linking any detectable p4E-BP1 with poor survival (univariate log rank P=0.001; multivariate HR 8.8, P=0.0001).

Conclusions:

Our data provide no support for direct therapeutic targeting of eIF4E in male breast cancer, unlike in females. However, as p4E-BP1 gives powerful prognostic insights that are unrelated to eIF4E function, p4E-BP1 may identify male breast cancers potentially suitable for therapies directed at the upstream kinase, mTOR.

Male Breast Cancer: Clinical Features and Multimodal Treatment in a Retrospective Survey Analysis at Italian Centers

Aims and background

We report a collection of data about early breast cancer in male patients from 13 Italian institutions.

Methods and study design

We obtained data from patient charts and performed statistical analysis. The primary end points were overall survival and disease-free survival.

Results

A total of 205 men with invasive breast cancer was identified, with a median age of 66 years. Pathological characteristics were heterogeneous for T stage, N stage and HER2 status. Histological subtype was predominantly ductal infiltrating carcinoma. Most of them were hormone receptor positive. Mastectomy was the most common strategy. Postsurgical treatment was not standardized. Patients with large tumors were more likely to be treated with chemotherapy. Disease recurrence was associated with an ER+ and PR+ status.

Conclusions

We identified a correlation between relapse and hormone receptor expression, as is the case in female breast cancer.

Poor compliance with breast cancer treatment guidelines in men undergoing breast-conserving surgery

Lumpectomy is performed in a small but growing proportion of men with breast cancer. It is unknown whether men undergoing breast-conserving surgery (BCS) receive care compliant with breast cancer treatment guidelines. Patients with breast cancer in the surveillance, epidemiology, and end results (SEER) database who underwent lumpectomy between 1983 and 2009 were identified. Gender differences in the receipt of lymph node staging and adjuvant radiation therapy were assessed. Multivariate logistic regression was utilized to evaluate the independent association of gender on these outcomes. The influence of gender on breast cancer-specific survival (BCSS) was analyzed. 382,030 of 824,408 (46.3 %) women compared to 712 of 6,039 (11.8 %) men with breast cancer underwent lumpectomy. Men were older, more likely to be black, less likely to have stage I disease and more likely to have stage IV disease. Only 59.2 % of men had lymph nodes sampled at the time of surgery compared to 81.6 % of women (p < 0.0001). In addition, only 35.4 % of men received adjuvant breast radiation therapy compared to 69.8 % of women (p < 0.0001). After controlling for age, race, stage, grade, and year of diagnosis, female gender was significantly associated with receiving adjuvant radiation therapy (OR 2.9, 95 % CI 2.4-3.4) and lymph node staging (OR 1.6, 95 % CI 1.3-1.90). Five- and ten-year BCSS were 88.0 and 83.5 % for men compared to 93.2 and 88.2 % for women (p < 0.001). Men with breast cancer are less likely to receive lymph node staging or adjuvant radiation therapy following BCS compared to women.

Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship

BACKGROUND

The causes, optimal treatments, and medical/psychosocial sequelae of breast cancer in men are poorly understood.

DESIGN

A systematic review of the English language literature was conducted to identify studies relevant to male breast cancer between 1987 and 2012 and including at least 20 patients. Searches were carried out on PubMed using the title terms 'male breast cancer' or 'male breast carcinoma'.

RESULTS

Relevant published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation and treatment, and survivorship issues in male breast cancer patients are presented. BRCA2 mutations, age, conditions that alter the estrogen/androgen ratio, and radiation are proven risk factors. Disease biology is distinct in men, but diagnostic approaches and treatments for men are generally extrapolated from those in women due to inadequate research in men. Survivorship issues in men may include sexual and hormonal side-effects of endocrine therapies as well as unique psychosocial impacts of the disease.

CONCLUSION

Further research is needed to address gaps in knowledge pertaining to care of male breast cancer patients and survivors.